Provider exclusion
A provider exclusion is a federal action — commonly listing on the OIG LEIE — that bars a provider from billing federal healthcare programs; claims from excluded providers are not payable.
Updated
A provider exclusion is a federal action that removes a provider's eligibility to participate in federal healthcare programs. The most common source is the HHS Office of Inspector General's List of Excluded Individuals/Entities (LEIE); another is the General Services Administration's System for Award Management (SAM.gov) exclusion list. Exclusion can follow a criminal conviction, program abuse, patient neglect, or other listed grounds.
Claims submitted by or billed under an excluded provider for services furnished while excluded are not payable by Medicare, Medicaid, or other federal programs, and payment received for such services is an overpayment and can carry further liability. Exclusion can apply to an individual or, in some cases, to an organization.
In practice
Because payment to an excluded provider is not recoverable and can expose the practice, screening staff and contracted providers against the LEIE before hire and on a routine schedule is a standard compliance control. An excluded provider cannot be billed under another's NPI to circumvent the exclusion, and the exclusion is not automatically lifted — reinstatement requires a formal request.
Commonly confused with
- Provider enrollment: Enrollment is the per-payer process of being approved to bill a specific program; exclusion is a federal bar on billing any federal program, which enrollment screening is meant to catch before claims are submitted.